Basic Information
Provider Information | |||||||||
NPI: | 1497183347 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KUBAT | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | LYN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DRYDEN | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | LYN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 687 CHESHIRE AVE | ||||||||
Address2: |   | ||||||||
City: | EUGENE | ||||||||
State: | OR | ||||||||
PostalCode: | 974025060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5416844100 | ||||||||
FaxNumber: | 5416844165 | ||||||||
Practice Location | |||||||||
Address1: | 1651 CENTENNIAL BLVD | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | OR | ||||||||
PostalCode: | 974773363 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5417624534 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/30/2013 | ||||||||
LastUpdateDate: | 04/25/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | 1497183347 | 05 | OR |   | MEDICAID |